The Examination a Month after Delivery:

Family Planning

A patient should be seen in her physician’s office about one month after confinement for a thorough examination. This visit is an integral part of good obstetric care. It furnishes the physician an opportunity to take stock of his results, gives the patient the advantage of having any abnormality corrected, and offers patient and doctor a logical opening to discuss future pregnancies.

If at the time of the scheduled visit the patient is menstruating, it is preferable to make another appointment. Of course menstruation must be distinguished from abnormal non-menstrual bleeding or staining, for if this is the case there is all the more reason to keep the date. When there is doubt the doctor can frequently differentiate the two over the telephone by the patient’s description of the bleeding.

The Visit

A pertinent history is taken, including ability to control urine and stool, pain in the perineal region, return of menses, lactation, etc.

Pregnancy Spacing

The discussion then turns to plans concerning more children. Frequently the patient asks, ‘How many children should we have, and how far apart should they be spaced?’ There is no pat answer, no precise formula. The physician can be certain of several facts. First, youth is a respected ally of successful pregnancy and delivery. Second, no physical harm has been proved to result from having children close together. Third, both great parity and a woman’s relatively advanced reproductive age penalize the efficiency and safety of childbirth. These facts are presented to the patient, and the couple has to plan accordingly.

Obviously, special factors may put the woman in an individual category, so that the doctor may feel it necessary to offer specific advice rather than generalities. I am listing here some of the commoner conditions which make a short in- terval between the termination of one pregnancy and the beginning of the next advisable. 1. A woman has started her family at the age of thirty-five or more and wants several children. 2. Moderate-sized fibroid tumors of the uterus are present and their removal is not contemplated. Since the speed of their growth is unpredictable, one had better make hay while the sun shines. 3. When pregnancy has just resulted in an abortion or the death of the newborn, it is psychically imperative for most women to conceive at once. No substitute will eradicate the sense of frustration. 4. The couple in whom it required several years to achieve a pregnancy cannot afford to wait, for it is impossible to know whether relative infertility will thwart them again. Usually it does not.

I have seen no ill effects in the normal woman from a new pregnancy starting ten or twelve weeks after the completion of her last.

There are also conditions which argue vehemently in favor of the lengthy postponement of a new pregnancy. For these patients time must elapse so that one may evaluate the effects of the completed pregnancy and newly acquired parenthood on the physical abnormality. A partial list follows: 1. Malignancy, particularly breast. No pregnancy should be undertaken for five years after the breast operation. 2. Heart disease, more than slight. 3. Active or recently active tuberculosis. 4. Persistent high blood pressure. 5. A psychiatric disturbance in pregnancy or the puer-perium.

Neither list is intended to be complete; each indicates the philosophy of the physician in this area of thought.

The observant reader will notice that Cesarean section, diabetes, pre-eclampsia, and eclampsia do not appear above. Their omission was purposeful, since I do not feel that any of the four should affect the time interval between pregnancies.

Contraceptive Advice

When a physician advises against further pregnancies or prescribes a long interval between them, I think it is cruel to do so without finding out whether the couple is experienced in the use of contraception. If they are not, it is his obligation to give contraceptive advice—or, if he feels that he is not qualified to do so, to refer them to a properly qual- ified colleague. On the other hand, if the physician is restrained from prescribing mechanical or chemical means of conception control because of his own or the couple’s religious beliefs he should instruct them in the accurate employment of the ‘safe period.’ If he is Catholic and the couple is not, he may prefer to send them to another physician with different beliefs about the ethical propriety of the other means of birth control.

When a couple has practiced contraception effectively and with mutual sexual satisfaction the doctor is unlikely to suggest a change of technique, no matter how inferior he may regard their method. On the other hand, when a couple has had no contraceptive experience, or the form of birth control previously employed was unsatisfactory to either the wife or husband, the doctor should discuss in detail available methods, help choose the one which seems best suited, and give thorough instruction.

I realize full well that contraception is still a controversial topic, and, if you share my views but your doctor does not, get in touch with your local Planned Parenthood Clinic or write to the National Planned Parenthood Federation, 501 Madison Avenue, New York 22, New York. The latter will refer you to either a clinic or a private physician in your area, depending on availability and your preference—and whether or not you reside in Massachusetts or Connecticut, since the dispensing of contraceptive information or materials is illegal in these two states. Both the prescription and practice of contraception are legal in the other forty-eight states.

There are many methods of contraception, some 4000 and more years old, others brand new. Among the many methods there are several which are highly effective. Before mentioning individual techniques I should like to state a few generalizations. 1. Any method of contraception is more likely to prevent an undesired pregnancy than none at all. Nature despises an untenanted womb and she constantly strives to populate it. 2. A highly acceptable birth-control method for couple ‘A’ may be rejected by couple ‘B.’ Therefore experimentation with methods is a good idea to find out which is the most desirable for the couple involved. 3. A highly efficient method used irregularly is not as efficient as a less effective method used conscientiously.

Now, let us say a word about methods. 1. The birth-control pill is the most trustworthy method of contraception yet devised. Actually it is 100 per cent safe, if used precisely as prescribed. It is estimated that 500,- 000 to 1,000,000 women are using it in the U.S. today (April, 1962). It may only be obtained by prescription from a physician. The two pills now being marketed are Enovid and Ortho-Novum.

A pill is taken daily for 20 consecutive days beginning on the 5th day of the menstrual cycle, counting the first day of menstruation as day one. Then after the 20th pill they are stopped. Ordinarily a new period commences 48 to 96 hours later. This all sounds too good to be true. Disadvantages are that 20 per cent of users develop temporary side effects while using the pills, such as nausea, vomiting, breast-fullness, tendency to gain weight, vaginal staining, etc. Then, too, the pills must still be gotten by prescription, and they are expensive. 2. The condom or the male sheath is still strongly recommended. It is ideal for some couples. 3. The diaphragm, made of soft rubber, in the shape of a shallow cup, with a flexible metal spring forming the circular outer edge, serves to dam off the lower from the upper vagina. When intercourse occurs the sperm cells are deposited in the lower vagina and are prevented by the diaphragm from reaching the upper vagina where the cervix is located. Each woman must be individually fitted for a diaphragm and taught how to insert and remove it. The diaphragm properly used is an excellent method of birth control. 4. Aerated contraceptive cream, marketed as Emko, is deposited in the vagina by means of plastic syringe just before intercourse. The method is simple and quite reliable. 5. There are many other chemical methods such as non-aerated creams and jellies, tablets and suppositories. These are probably less reliable. 6. Coitus iterruptus (withdrawal) and douching after intercourse are mentioned to be condemned. They are relatively inefficient and undesirable. Still, they are better than no method. 7. Rhythm. The rhythm method employs timed abstinence. In other words, the couple abstains from intercourse around the likely time of ovulation, practicing sex relations only several days before and several days after the calculated ‘unsafe’ period, that is, the day of ovulation. To figure out the safe period follow these directions: 1. Keep a written record of your menstrual cycle for 12 consecutive months. Count the first day of menstruation as day 1 of the cycle, and the day before the next period as the last day of the cycle. At the end of 12 months, figure out how many days were in your shortest cycle and how many in your longest. 2. Subtract 18 from the number of days in your shortest cycle. This determines the first fertile, or unsafe, day of your cycle. 3. Subtract 11 from the number of days in your longest cycle. This determines the last fertile day of your cycle, or the day on which your unsafe period ends.

Here is an example of how this works. Let us say that during the previous year your cycles ranged from 26 to 29 days in length. Your fertile period would be from the 8th day (26 days minus 18) to the 18th day (29 days minus 11). Counting from the first day of menstruation, it would be safe to have intercourse until the 8th day, and after the 18th day. It would be unsafe during the 11 days in between.

Sterilization

In contrast to contraception, which is temporary conception control, sterilization is permanent and irrevocable conception control. Sterilization can be performed on either the wife or husband, but in neither is it ordinarily reversible. In the female it consists of tying and cutting each Fallopian tube so that sperm and ovum can never meet. In the male the vas deferens, the tube carrying the sperm cells from their site of production in the testis to the penis, is interrupted on both sides in the upper part of the scrotum. Thereafter the ejaculate, very little lessened in amount, contains no spermatozoa. No tissue is removed in sterilization of either male or female, so that there is no alteration in physiologic status. Menstruation continues unchanged; libido and orgasm capacity remain unaltered.

Sterilization of women is usually done by an abdominal operation, though in some instances it may be carried out in the course of a vaginal operative procedure. The former may be done at the time of Cesarean section, or several hours or days after delivery, or during the nonpregnant state. Sterilization in the female entails several days of hospitalization. Because of this most sterilizations are now performed a few hours after delivery, if indications for sterilization coincide with the termination of a pregnancy, for then the single hospital admission accomplishes two things, delivery and sterili- zation. Also, technically the procedure is particularly simple immediately postpartum.

The sterilization of the male can be done under local anesthesia in the physician’s office, but most doctors prefer the hospital. Ordinarily the man is hospitalized for forty-eight to seventy-two hours. Sterilization of the male is a less difficult procedure than sterilizing the female.

The indications for sterilization include only conditions which make any further pregnancy unwise, as, for example, such serious heart disease that another pregnancy might be fatal, or a psychiatric condition which makes additional parenthood forever undesirable.

I have not gone into the legal aspects of sterilization, since the topic is not germane to our discussion. Suffice it to say that each state and each hospital has its own laws and rules. For further information the reader may write to the Human Betterment Association, 105 West 55th Street, New York 19, New York. Ordinarily a normal couple cannot simply request sterilization and have it granted without reasonable medical grounds, although I am happy to report that reasonable grounds are becoming increasingly more lenient. Of course sterilization is not performed without the knowledge and consent of the couple.

We have wandered a long distance from the postpartum examination; now, to get back to it, let us assume that you and your doctor have completed your conversation and he has sent you into the examining room.

Postpartum Examination

After voiding, you undress, wrap yourself in a sheet, and are weighed. Then, properly draped, you lie on your back on the examining table. The doctor enters and examines your breasts and abdomen. When this is completed, your heels are placed in stirrups and you bring your buttocks to the edge of the table with knees spread wide apart. The doctor inserts his gloved index and middle fingers within the vagina and by downward pressure tests his perineal repair. More than likely he is quite proud of his seamstry. He then checks the uterus, tubes, and ovaries by bimanual examination. If he plans to fit you with a contraceptive diaphragm, it is usually done at this juncture. Then either the doctor or his nurse instructs you carefully in its insertion and removal. When this is completed, a two-bladed metal speculum is inserted in the vagina and manipulated so that the cervix is brought in clear view. If any raw area is visible on the lips of the cervix it is seared by a red-hot electric cautery tip. This sounds barbaric but, since the cervix is devoid of pain nerves, I promise you that it does not hurt; you may feel the heat, however. Frequently a rectal examination is made to check for the presence of hemorrhoids.

In indicated cases blood pressure, blood, and urine may be examined.

Finale

When you are dressed the doctor will discuss the results of the examination and offer any necessary advice. Some physicians make it routine to see all patients again six and twelve months after delivery.

The more than seven months of long, close acquaintanceship between doctor and patient are about to end. It is the unusual patient who does not express gratitude. Most obstetricians remain lifelong friends to the couples they have served. By being constantly associated in the parents’ thoughts with the happiness and pleasures of parenthood, the accoucheur occupies a unique position in the medical hierarchy, a very favorable position near the top.

Resumption of Sex Relations

If no abnormality is found at the postpartum examination, coitus may be immediately resumed. If cauterization of the cervix was performed, abstinence should be practiced for another week. If at the resumption of marital relations the scar of the perineal tear or episiotomy causes pain, this can be diminished by a prelininary hot bath, and if both individuals lubricate beforehand with Vaseline or some jelly or cream. When pain or discomfort persists for more than four weeks, after resumption of sexual relations, the patient should return to her doctor for treatment. The vaginal opening can either be stretched digitally or dilated with appropriate dilators. Contraception should be used if immediate reim-pregnation is not desired. Fertility may be at a low ebb for a few months after birth, but it is not reliably absent.